A charge nurse on a mental health unit is receiving change of shift report for a group of clients. The charge nurse is working with an RN, an LPN, and assistive personnel (AP) from 0700 to 1900 and is reviewing client care assignments. Complete the following sentence by using the lists of options.
The charge nurse should first assess the client who has a 7-year history of major depressive disorder, whose friend reports the client has stopped taking their medication, and who is flat, withdrawn, cries all the time, sleeps all the time, and has extremely slowed movements, due to the risk of Select.
suicide
dehydration
infection
seizure
The Correct Answer is A
Choice A reason: The risk of suicide is the highest priority for the charge nurse to assess. The client has several risk factors for suicide, such as major depressive disorder, medication noncompliance, hopelessness, social isolation, and psychomotor retardation. The charge nurse should evaluate the client's suicidal ideation, intent, and plan, and implement safety measures as needed.
Choice B reason: The risk of dehydration is a lower priority than the risk of suicide. The client may be dehydrated due to decreased fluid intake, but this is not a life-threatening condition. The charge nurse should monitor the client's hydration status and encourage oral fluids as appropriate.
Choice C reason: The risk of infection is a lower priority than the risk of suicide. The client does not have any signs or symptoms of infection, such as fever, chills, or leukocytosis. The charge nurse should assess the client's vital signs and laboratory results as indicated, but this is not an urgent issue.
Choice D reason: The risk of seizure is a lower priority than the risk of suicide. The client does not have any history or risk factors for seizure, such as epilepsy, head trauma, or drug withdrawal. The charge nurse should observe the client for any abnormal movements or behaviors, but this is not a likely complication.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Respecting the client's decision and informing the provider is an appropriate action, but not the first one that the nurse should take. The nurse should first assess the client's understanding of the condition and the treatment options, and provide education and support as needed.
Choice B reason: Explaining the benefits and risks of the procedure is an appropriate action, but not the first one that the nurse should take. The nurse should first assess the client's understanding of the condition and the treatment options, and provide education and support as needed.
Choice C reason: Suggesting alternative treatments for the condition is an appropriate action, but not the first one that the nurse should take. The nurse should first assess the client's understanding of the condition and the treatment options, and provide education and support as needed.
Choice D reason: Assessing the client's understanding of the consequences of uterine prolapse and the need for surgery is the first and most appropriate action that the nurse should take. The nurse should determine the client's knowledge, beliefs, and preferences regarding the condition and the surgery, and address any gaps, misconceptions, or concerns. The nurse should also respect the client's autonomy and right to make informed decisions about their health care.
Correct Answer is D
Explanation
Choice A reason: A middle adult client who leaves the facility against medical advice does not require the involvement of the ethics committee. The nurse should document the client's decision, inform the provider, and provide discharge instructions.
Choice B reason: A young adult client who is participating in a medical research study does not require the involvement of the ethics committee. The nurse should ensure that the client has given informed consent and is aware of the potential risks and benefits of the study.
Choice C reason: An older adult client who has advance directives on file does not require the involvement of the ethics committee. The nurse should respect the client's wishes and follow the directives in case of a life-threatening situation.
Choice D reason: An adolescent client whose parents refuse a blood transfusion for religious reasons requires the involvement of the ethics committee. The nurse should consult the ethics committee to help resolve the conflict between the parents' beliefs and the client's best interests. The ethics committee can also provide guidance on the legal and ethical implications of the situation.
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